"Without antibiotics, I cannot treat": A qualitative study of antibiotic use in Paschim Bardhaman district of West Bengal, India.

BACKGROUND: Misuse of antibiotics is a well-known driver of antibiotic resistance. Given the decentralized model of the Indian health system and the shortage of allopathic doctors in rural areas, a wide variety of healthcare providers cater to the needs of patients in urban and rural settings. This qualitative study explores the drivers of antibiotic use among formal and informal healthcare providers as well as patients accessing care at primary health centers across Paschim Bardhaman district in West Bengal. MATERIALS AND METHODS: We conducted 28 semi-structured, in-depth interviews with four groups of healthcare providers (allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers) as well as patients accessing care at primary health centers and hospitals across Paschim Bardhaman district. Qualitative data was analyzed using the framework method in an inductive and deductive manner. RESULTS: Our results indicate that patients demand antibiotics from healthcare providers and seek the fastest cure possible, which influences the prescription choices of healthcare providers, particularly informal health providers. Many allopathic doctors provide antibiotics without any clinical indication due to inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions. Pharmaceutical company representatives actively network with informal health providers and formal healthcare providers alike, and regularly visit providers even in remote areas to market newer antibiotics. Allopathic doctors and informal health providers frequently blame the other party for being responsible for antibiotic resistance, and yet both display interdependence in referring patients to one another. CONCLUSIONS: A holistic approach to curbing antibiotic resistance in West Bengal and other parts of India should focus on strengthening the capacity of the existing public health system to deliver on its promises, improving patient education and counseling, and including informal providers and pharmaceutical company representatives in community-level antibiotic stewardship efforts.

Seven key actions to eradicate rheumatic heart disease in Africa: the Addis Ababa communiqué.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain major causes of heart failure, stroke and death among African women and children, despite being preventable and imminently treatable. From 21 to 22 February 2015, the Social Cluster of the Africa Union Commission (AUC) hosted a consultation with RHD experts convened by the Pan-African Society of Cardiology (PASCAR) in Addis Ababa, Ethiopia, to develop a 'roadmap' of key actions that need to be taken by governments to eliminate ARF and eradicate RHD in Africa. Seven priority areas for action were adopted: (1) create prospective disease registers at sentinel sites in affected countries to measure disease burden and track progress towards the reduction of mortality by 25% by the year 2025, (2) ensure an adequate supply of high-quality benzathine penicillin for the primary and secondary prevention of ARF/RHD, (3) improve access to reproductive health services for women with RHD and other non-communicable diseases (NCD), (4) decentralise technical expertise and technology for diagnosing and managing ARF and RHD (including ultrasound of the heart), (5) establish national and regional centres of excellence for essential cardiac surgery for the treatment of affected patients and training of cardiovascular practitioners of the future, (6) initiate national multi-sectoral RHD programmes within NCD control programmes of affected countries, and (7) foster international partnerships with multinational organisations for resource mobilisation, monitoring and evaluation of the programme to end RHD in Africa. This Addis Ababa communiqué has since been endorsed by African Union heads of state, and plans are underway to implement the roadmap in order to end ARF and RHD in Africa in our lifetime.

Inpatient care of small and sick newborns: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: Preterm birth is the leading cause of child death worldwide. Small and sick newborns require timely, high-quality inpatient care to survive. This includes provision of warmth, feeding support, safe oxygen therapy and effective phototherapy with prevention and treatment of infections. Inpatient care for newborns requires dedicated ward space, staffed by health workers with specialist training and skills. Many of the estimated 2.8 million newborns that die every year do not have access to such specialised care. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" (or factors that hinder the scale up) of maternal-newborn intervention packages. For this paper, we used quantitative and qualitative methods to analyse the bottleneck data, and combined these with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for inpatient care of small and sick newborns. RESULTS: Inpatient care of small and sick newborns is an intervention package highlighted by all country workshop participants as having critical health system challenges. Health system building blocks with the highest graded (significant or major) bottlenecks were health workforce (10 out of 12 countries) and health financing (10 out of 12 countries), followed by community ownership and partnership (9 out of 12 countries). Priority actions based on solution themes for these bottlenecks are discussed. CONCLUSIONS: Whilst major bottlenecks to the scale-up of quality inpatient newborn care are present, effective solutions exist. For all countries included, there is a critical need for a neonatal nursing cadre. Small and sick newborns require increased, sustained funding with specific insurance schemes to cover inpatient care and avoid catastrophic out-of-pocket payments. Core competencies, by level of care, should be defined for monitoring of newborn inpatient care, as with emergency obstetric care. Rather than fatalism that small and sick newborns will die, community interventions need to create demand for accessible, high-quality, family-centred inpatient care, including kangaroo mother care, so that every newborn can survive and thrive.

Prenatal care and basic emergency obstetric care services provided at primary healthcare facilities in rural Nigeria.

OBJECTIVE: To assess the availability of prenatal care and basic emergency obstetric care services at primary healthcare (PHC) facilities in rural Nigeria. METHODS: In total, 652 PHC facilities enrolled in the Midwives Service Scheme, a government-funded program designed to reduce the national shortage of skilled birth attendants, were surveyed. RESULTS: In all, 44.0% of the PHC facilities evaluated did not provide all components of prenatal care, and only 39.0% of all pregnant women nationwide attended prenatal care clinics 4 or more times. In addition, 52.2% of the facilities were not distributing insecticide-treated nets to pregnant women, while only 36.8% of the PHC facilities provided services to prevent mother-to-child transmission of HIV. By contrast, 70.0% of the PHC facilities had access to antibiotics for the treatment of uncomplicated sepsis. Only 11.0% of clinics reported the use of vacuum extraction during labor and 36.8% provided post-abortion care services. Treatment for pre-eclampsia and eclampsia was initiated at 40.0% and 28.0% of PHC facilities, respectively, prior to referral. CONCLUSION: The present study provides useful information on the state of prenatal and basic emergency obstetric care in rural Nigeria. The data obtained indicate that changes are needed to achieve related Millennium Development Goals.

Changes in the use of broad-spectrum antibiotics after cefepime shortage: a time series analysis.

The original cefepime product was withdrawn from the Swiss market in January 2007 and replaced by a generic 10 months later. The goals of the study were to assess the impact of this cefepime shortage on the use and costs of alternative broad-spectrum antibiotics, on antibiotic policy, and on resistance of Pseudomonas aeruginosa toward carbapenems, ceftazidime, and piperacillin-tazobactam. A generalized regression-based interrupted time series model assessed how much the shortage changed the monthly use and costs of cefepime and of selected alternative broad-spectrum antibiotics (ceftazidime, imipenem-cilastatin, meropenem, piperacillin-tazobactam) in 15 Swiss acute care hospitals from January 2005 to December 2008. Resistance of P. aeruginosa was compared before and after the cefepime shortage. There was a statistically significant increase in the consumption of piperacillin-tazobactam in hospitals with definitive interruption of cefepime supply and of meropenem in hospitals with transient interruption of cefepime supply. Consumption of each alternative antibiotic tended to increase during the cefepime shortage and to decrease when the cefepime generic was released. These shifts were associated with significantly higher overall costs. There was no significant change in hospitals with uninterrupted cefepime supply. The alternative antibiotics for which an increase in consumption showed the strongest association with a progression of resistance were the carbapenems. The use of alternative antibiotics after cefepime withdrawal was associated with a significant increase in piperacillin-tazobactam and meropenem use and in overall costs and with a decrease in susceptibility of P. aeruginosa in hospitals. This warrants caution with regard to shortages and withdrawals of antibiotics.

Pertussis prevention and treatment: a call for wider access to azithromycin.

Azithromycin is recommended as the first-line antibiotic for the prophylaxis and treatment of pertussis, a common vaccine-preventable communicable disease. Azithromycin is better tolerated than other macrolide antibiotics. Access to azithromycin is limited, as the product information and the Pharmaceutical Benefits Scheme do not include azithromycin for pertussis. Issues regarding access to azithromycin are highlighted in a case report of pertussis exposure in a tertiary paediatric hospital.

Tigecycline: a new antibiotic.

Tigecycline is a novel antimicrobial agent recently licensed in the United Kingdom (UK), United States and Europe. It is a broad spectrum glycylcycline antibiotic which has structural similarities to the tetracyclines but is more potent against tetracycline-resistant organisms. It is only available as an intravenous (IV) preparation. This article reviews the clinical efficacy, side effect profile, dosing and administration schedule of tigecycline. The article also discusses the warnings and precautions associated with the use of this drug. Tigecycline may be used for complicated intra-abdominal and complicated skin and soft tissue infections. It is also likely to find a role in the treatment of infections caused by multi-resistant organisms such as Acinetobacter species.

[Imipenem resistance in Gram-negative rods and its consumption between 1999 and 2005]. / Opornosc paleczek Gram-ujemnych na imipenem a zuzycie tego leku w latach 1999-2005.

Multidrug resistant Gram-negative rods are increasingly isolated from clinical specimens, especially from hospitalized patients. The aim of this study was to evaluate the prevalence of imipenem resistant strains of Gram-negative rods isolated in dr. A. Jurasz University Hospital in Bydgoszcz between 1999 and 2005 and imipenem consumption in this period. Out of 109614 isolated microorganisms, Gram-negative rods were 28,5%, 637 (2,0%) of strains were resistant to imipenem. These strains were isolated mostly from patients hospitalized in intensive care and rehabilitation clinics. Among imipenem-resistant strains Pseudomonas aeruginosa prevailed (88,9%). P. aeruginosa strains were sensitive to colistin, 45,5% of them to aztreonam and 44,0% to ceftazidime. The imipenem consumption in the appropriate years included in this study was: 805,00; 1201,25; 940,00; 1390,00; 1660,00; 1341,25; 1841,25 DDD respectively, and was strictly connected with increasing imipenem-resistant Gram-negative rods isolation.

Antimicrobial resistance in developing countries. Part II: strategies for containment.

The growing threat from resistant organisms calls for concerted action to prevent the emergence of new resistant strains and the spread of existing ones. Developing countries have experienced unfavourable trends in resistance-as detailed in part I, published last month--and implementation of many of the containment strategies recommended by WHO is complicated by universal, as well as developing country-specific, factors. The control of selective pressure for resistance could potentially be addressed through educational and other interventions for orthodox and unorthodox prescribers, distributors, and consumers of antimicrobials. At national levels, the implementation of drug use strategies--eg, combination therapy or cycling--may prove useful to lengthen the lifespan of existing and future agents. Programmes such as the Integrated Management of Childhood Illnesses (IMCI) and directly observed short-course therapy (DOTS) for tuberculosis are prescriber-focused and patient-focused, respectively, and have both been shown to positively influence factors that contribute to the selective pressure that affects resistance. The institution of interventions to prevent the transmission of infectious diseases could also lead to beneficial effects on the prevalence of resistance, as has vaccination against Haemophilus influenzae type B and Streptococcus pneumoniae. There has been an upsurge in the number of organisations and programmes that directly address issues of resistance, and collaboration could be one way to stem the dire trend. Additional factors such as unregulated drug availability, inadequate antimicrobial drug quality assurance, inadequate surveillance, and cultures of antimicrobial abuse must be addressed to permit a holistic strategy for resistance control.

The relation between sale of antimicrobial drugs and antibiotic resistance in uropathogens in general practice.

BACKGROUND: Overuse of antimicrobial drugs has resulted in an alarming increase in bacterial resistance in most countries. The relevance for general practice is unknown. OBJECTIVE: To evaluate the impact of the sale of antimicrobial drugs on bacterial resistance as found in uropathogens from general practice. SETTING: General practice in Belgium and Norway. METHODS: Observational study. RESULTS: The sale of antimicrobial drugs indicated for use in the treatment of urinary tract infection was four times higher in Belgium than in Norway (18.5 vs 4.4 DDD/1000 inhabitants/day). The antibiotic resistance reported by microbiological laboratories as valid for general practice was significant higher in Belgium than in Norway (ampicillins (44% vs 27%), co-trimoxazole (28% vs 17%), fluoroquinolones (12% vs 2%) and nitrofurantoin (16% vs 11%, p < 0.0001 for all). However, the antibiotic resistance found in urine samples from dysuric women in general practice was similar (trimethoprim 14% vs 12%, co-trimoxazole 14% vs 11%, nitrofurantoin 7% vs 3%), except in the case of ampicillins (30% vs 19%, p < 0.05). CONCLUSION: The impact of the antimicrobial sale on resistance in uropathogens seems less than expected at the general practice level, even though local microbiological reports mention fairly high antibiotic resistance data. Adapted methods for following-up bacterial resistance evolution in general practice are needed.

Death from multi-resistant shigellosis in Fiji Islands.

Death from Shigellosis is rare in developed countries, however it causes over a million deaths in developing countries worldwide annually. Death from shigellosis is rare in Fiji. However, the global problem of emerging multidrug resistance raises some issues about the management of Shigellosis in this country. Within Fiji, Shigella is a notifiable disease. The Fiji Ministry of Health recorded 68 cases of Shigella in 1996, 173 cases in 1997 and 334 cases in 1998 (no data available for 1999). There was only one recorded death during this time--in 1998. Resistance to chloramphenicol occurred in 82% of cases. Shigella flexneri in Fiji remains sensitive to cephalothin and cefaclor. The current antibiotic guidelines in Fiji, recommend that antibiotics be used only for cases of moderate and severe dysentery. Shigellosis was suspected soon after presentation however the patient was unable to take oral antibiotics and was treated with intravenous antibiotics (chloramphenicol and ampicillin), which were ineffective due to resistance of the organism. The current antibiotic guidelines for severe dysentery recommend chloramphenicol or nalidixic acid--the later not available in Fiji. However the only intravenous drugs that retain their sensitivity to Shigella-ceftriaxone and cephalothin, are expensive ($F 45.00 per vial of ceftriaxone) and these are only available in large regional hospitals.

The cost effective medical treatment of suppurative otitis media in a Nigerian environment.

The microbes isolated from the cultures taken from the discharging ears of 63 patients with Otitis media treated in a hospital in Warri in 1991 were analysed. Pseudomonas, streptococcus, Staphylococcus and Proteus were the major organisms isolated in order of their prevalence. All show highest sensitivity to Gentamycin. The author found 24 aural preparations in the MIMS of 1992 and checked the availability and cost of these in the Nigeria environment and came out with the possible cost effective suggestions for the treatment of acute otitis media in this environment based on these micro-organisms.

Antibiotic policy.

Antibiotics are often effective in curing a patient of his infection even when used in a suboptimal manner. In this situation it is often difficult for the prescriber to accept that he/she is using antibiotics "badly" when he can point to the majority of his infections responding well--either to the antibiotic or the patient's own immune response. Many attempts have been made to limit antibiotic use by selective laboratory reporting, by restricting the antibiotics available, by producing guidelines for initial therapy of infection or prophylaxis, by involvement of infectious disease specialists in all antibiotic use and by several other systems. It appears, however, that antibiotic use is still heavily criticised and is a continuing source of conflict in medicine. Consensus on antibiotic indications is still difficult to obtain and is likely to be achieved very slowly. It is clear that polemic is not sufficient and that consensus practices can only be based upon firm scientifically acquired data and detailed discussion of the options by those most intimately involved.